Provider Demographics
NPI:1104139377
Name:O'CONNELL, LISA (PT MS PCS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:PT MS PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1942
Mailing Address - Country:US
Mailing Address - Phone:909-237-1714
Mailing Address - Fax:
Practice Address - Street 1:200 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1942
Practice Address - Country:US
Practice Address - Phone:732-258-7102
Practice Address - Fax:732-258-7231
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40 QA 00346500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist